Impact of intraoperative remifentanil on postoperative pain and opioid use in thyroid surgery

Wu, James X.; Assel, Melissa; Afonso, Anoushka M.; Twersky, Rebecca S.; Simon, Brett A.; Cohen, Marc A.; Rieth, Elizabeth F.; Cracchiolo, Jennifer R.

doi:10.1002/jso.25746

Cited by 15 publications

(14 citation statements)

References 20 publications

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“…There were 24 studies identified, including 6 RCTs, 13 prospective observational studies, and 5 retrospective observational studies, that described mean or median consumption with either the standard deviation or the 75th percentile. 147,152,153,164-185 Opioid consumption was initially converted into morphine milligram equivalent (MME) units 186 ( Table 15 ), and individual procedures were compared. MME is a value assigned to compare the opioid dosage equivalency to another opioid.…”

Section: Key Action Statementsmentioning

confidence: 99%

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Anne¹,

Mims

Tunkel

et al. 2021

Otolaryngol.--head neck surg.

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Objective Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. Purpose The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan. The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. Action Statements The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method. The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

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Section: Key Action Statementsmentioning

confidence: 99%

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Anne¹,

Mims

Tunkel

et al. 2021

Otolaryngol.--head neck surg.

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“…With the patient in the prone position with just a nasal cannula for continuous oxygen supply, the patient should not receive an intravenous dose of propofol higher than the recommended 1mg/kg IV. The continuous infusion was established at about 50 μg/kg/min [32]. When using the target-controlled infusion (TCI) technology, the aim was to maintain at 1 μg/mL concentration in the plasma, but it can vary depending on the respiratory drive.…”

Section: Center (Asc)mentioning

confidence: 99%

“…This pharmacokinetic and pharmacodynamic profile suggests that remifentanil will be useful in situations where a rapidly titratable potent opioids effect was desirable during the endoscopic spinal surgery with a predictable offset of action without prolonged respiratory depression [32]. The anesthesiologist should always keep in mind that remifentanil has a small central volume of distribution.…”

Section: Center (Asc)mentioning

confidence: 99%

“…Any postoperative sequelae including náusea, vomiting, urinary retention, dysphoric wake-up, and excessive postoperative surgical pain requiring additional narcotic pain medication administration in the PACU were recorded. Primary measures of surgical outcomes were assessed employing the modified Macnab criteria [32,33]. All patients were instructed to be seen in follow-up for examination and management of any problems at 2 and 6 weeks and then at 3, 6, 12, and 24 months postoperatively.…”

Section: Clinical Follow-upmentioning

confidence: 99%

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Anesthesia For Endoscopic Spine Surgery Of The Spine In An Ambulatory Surgery Center

Abrão¹,

Dowling

León

et al. 2020

GJAPM

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Background: Providing adequate anesthesia that caters to rapid turn-over in an outpatient ambulatory surgery center setting is sometimes as much of an art as it is a science. Outpatient spine surgery is characterized by shorter simplified versions of their inpatient counterparts carried out in a hospital setting. Objective:The monitored anesthesia care (MAC) and deep sedation with a laryngeal mask airway (LMA) in the prone position have received little attention in the anesthesia and spine surgery literature. The authors reviewed their clinical outcomes with the outpatient endoscopic spinal surgery in conjunction with these two types of anesthesias. Methods:We performed an analysis of perioperative anesthesia and clinical outcomes in 184 patients who underwent lumbar endoscopic spinal surgery in two outpatient ambulatory surgery centers. The 184 patients consisted of 90 (48.9%) women and 94 (51.1%) men with an average age of 54.3 ± 15.4 years. The average follow-up of 43.27 months. The primary clinical outcome measures were the modified Macnab criteria. Chi-square testing was employed to analyze statistically significant associations between the type of anesthesia, preoperative diagnosis, the surgical level(s), and surgeon requirements for MAC versus balanced general anesthesia.Results: At the final follow-up, the majority of patients had Excellent (93/184; 50.5%) and Good (74/184; 40.2%) Macnab outcomes regardless of treatment and anesthesia. There was minimal blood loss in all patients, and there were no complications such as dural tears, or hematomas. There were also no wound problems such as bleeding, or leaking of endoscopic irrigation fluid from the wound. Of the 184 study patients, 40 patients (21.7%) had a postoperative irritation of the dorsal root ganglion (DRG). The mean anesthesia time was 37 ± 9 minutes in patients under balanced general anesthesia. with LMA and 48 ± 12 minutes in MAC patients. All of the 184 patients were discharged under one hour from the PACU after an uneventful wakeup. Only six patients (3.26%) had postoperative nausea.Conclusions: Monitored anesthesia care with sedation in an ambulatory surgery center in the prone position is best suited for endoscopic spinal decompressions. Intubation of the patient with general anesthesia is generally not required. Most patients can be managed with a nasal cannula, face mask, or a balanced general anesthesia with a laryngeal mask airway (LMA).

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“…Remifentanil is a synthetic opioid that is commonly used during anaesthesia owing to its rapid onset, ultra-short duration of action and quick recovery ( Thompson and Rowbotham, 1996 ). Intraoperative use of remifentanil was, however, associated with paradoxically increased pain hypersensitivity, commonly known as opioid-induced hyperalgesia, and significant additional amount of opioid was required for postoperative analgesia, suggesting acute analgesic opioid tolerance ( Komatsu et al, 2007 , Guignard et al, 2000 , Crawford et al, 2006 , Suhitharan et al, 2018 , Wu et al, 2019 , de Hoogd et al, 2018 , Sanfilippo et al, 2016 , Grape et al, 2019 , Fletcher and Martinez, 2014 , Motamed et al, 2017 ). Development of acute opioid-induced receptor tolerance remains a major focus in understanding the underlying mechanism of this observation ( Guignard et al, 2000 , Vinik and Kissin, 1998 ).…”

Section: Introductionmentioning

confidence: 99%

Annexin A2 traps mu-opioid receptors in recycling endosomes upon remifentanil-induced internalization

Cheng

et al. 2021

Neurobiology of Pain

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Impact of intraoperative remifentanil on postoperative pain and opioid use in thyroid surgery

Cited by 15 publications

References 20 publications

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Anesthesia For Endoscopic Spine Surgery Of The Spine In An Ambulatory Surgery Center

Annexin A2 traps mu-opioid receptors in recycling endosomes upon remifentanil-induced internalization

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